SLHD - General Practitioner Incident Notification

General Practitioner Incident Notification

General Practitioner Incident Notification

This form can be used by GPs to report incidents experienced by their patients related to services provided by SLHD. An incident or injury includes: critical incidents and near misses; post-discharge problems, including post-operative complications and medication issues; problems encountered with accessing services for patients in SLHD; and communication problems.

Please complete the below form and submit.
* Mandatory fields.

Name and contact details of GP reporting incident

First Name: *

Last Name: *

Phone No: *

Email address: *

Postal address:

Patient's details

Patient's first name:

Patient's last name:

Date of Birth (DOB):

Have you discussed this matter with the patient?

Yes No

Description of Incident (include contributing factors) *

Investigation and Analysis: State any issues that have been investigated and analysed

Action taken by GP (include outcome)

Recommendations for planned action by Local Health District

Do you wish to discuss this event with SLHD Clinical Governance Unit? *

Yes No

Please note:

This is a web based form that is automatically forwarded to the SLHD Patient and Family Experience Team once submitted.

Once you have submitted this form, you can choose to download and save it as a PDF. We value your feedback and should you wish to contact us to discuss this concern or anything else you can do so via one of the methods below:

To SLHD Clinical Governance Unit either by

Email: SLHD-consumerfeedback@health.nsw.gov.au
Phone: 02 9515 9646, SLHD Director of Patient and Family Experience
Facsimile: 9515 9610

Postal address: SLHD, PO Box M30, Missenden Road, NSW, 2050

Required!